Pediatric Imaging Cases

Pediatric Imaging Cases

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Mysteries Solved with
Mysteries Solved with
Radiology
Radiology
Dorothy Bulas M.D.
David Kushner M.D.
Childrens National Medical Center
George Washington University
No disclosures by the authors
Objectives
Understand indications for imaging studies
Ultrasound
CT/MRI
Nuclear Medicine
Order appropriate radiologic work up for
Common diagnostic disorders
Imaging issues
Radiation exposure
Sedation risk
Cost
Discomfort
Fluoroscopy
Pro
No sedation
Indications
GI - malrotation, vascular rings, IBD,
ulcers,Hirsprung, strictures, aspiration
GU- Reflux, posterior urethral valves,
neurogenic bladder
Fluoroscopy
Con
Radiation exposure
Discomfort from catheterizations, nausea
Transportation
Temperature control
NPO for GI studies
Ultrasound
Pro
No radiation
Portable
No sedation
Inexpensive
Ultrasound
Indications
Masses/abscesses
Cranial- neonate, TCD for SSD
GI- pyloric stenosis, IBD, AP, biliary
GU- anatomy, Doppler, masses
Vascular- thrombi,stenosis,AVM
Extremities - hips,effusions
Ultrasound
Con
Small field of view
Crying, rapid breathing, gas, obesity
limits resolution
Limited resolution of solid organ
lesions
Technique dependent
CT Scan
Pro
Large field of view
Reproducible measurements
3D reconstruction
Vascular characteristics
CT Scan
Indications
Tumor staging and measurements
Reproducible
Lung, solid organ parenchymal lesions
well visualized
Vascular anatomy
Interloop abscess/bowel
Obese patients
CT Scan
Con
Radiation exposure!!
Possible sedation, NPO
Oral contrast 2- 4 hours
IV contrast- renal status, allergy hx
Transport issues, temperature control
Expense
MRI
Pro
Exquisite detail
Vascular characteristics-MRA/MRV
Large field of view
Multiple planes, 3D reconstruction
Spectroscopy
Cardiac physiology
MRI
Indications
Cranial/spine anatomy
Cardiac physiology
Solid Tumors
Infection - osteomyelitis/septic joint
AVM
Fetal anomalies
MRI
Con
Expensive
Long examination, sensitive to respiratory
and cardiac motion
Availability
Transport, temperature control
Sedation, NPO
+ IV access
Angiography
Pro
Precise anatomy
Therapeutic
Indications
Cranial- vasculitis, aneurysm, AMV
Renal- vascular stenosis
Pulmonary- embolization
Angiography
Con
Invasive- hematoma, stroke risk
Contrast - renal function,allergy
Sedation
Transportation
Temperature control
Radiation exposure
Nuclear Medicine
Pro
Physiologic information
Quantitative information
Therapeutic
Radiation may be less than fluoroscopy
Fusion PET/CT may improve resolution
Nuclear Medicine
Indication
Tumors- lymphoma,osteosarcoma, NB
Infection- osteomyelitis
Renal- reflux, function, obstruction
Hepatobiliary- function, obstruction
Meckels
Milk scan
Thyroid
Nuclear Medicine
Con
Radiation exposure
IV access
May require sedation
Poor resolution without fusion
imaging
Case
1 year old with unexplained burn
Nonaccidental Trauma
Skeletal survey
oblique for rib fractures
metaphyseal fractures
Cranial CT / MRI
Subdural hematomas
Abdominal CT
solid organ injuries
Bone scan- good
for confirmation,
rib fxs
or FU skeletal
survey after 2
weeks
Case
4 month old with stridor
STRIDOR
Croup
Epiglottitis
Vascular Rings
Foreign Body
Retropharyngeal Abscess
Croup
Subglottic
narrowing
Steeple sign
Ballooned
hypopharynx
Epiglotitis
Thumb sign
Thick
aryepiglottic
folds
Ballooned
hypopharynx
Retropharyngeal Abscess
Infection/laceration
Xray- prevertebral
soft tissue swelling
Fluoro
CT with contrast
STRIDOR
Foreign Body
Cough/wheeze
Inlet/Carina/GE
junction
Xray
insp/exp or decub
Esophogram
Vascular Rings
Aberrant branching of the
aortic arch
Double arch/ Aberrant
left subclavian Rt
Aortic arch/ Pulmonary
Sling
Compress
trachea/esophagus
Diagnose by
Barium swallow
Echo/
CT/
MRI
Neck Mass
Lymphoma-CT
Abscess-CT
Brachial cleft cyst- US,CT,MR
Thyroglossal duct cyst- US,CT,MR
Thyroid- nodule,Hashimoto thyroiditis,
papillary carcinoma- US, nuclear thyroid
scan
Case
2 week old with bilious vomiting
Malrotation with Volvulus
Clinical Presentation
Bilious vomiting
< 1 month in 80%
Bloody Stool
Abdominal distention
Surgical Emergency
Neonatal intestinal obstruction
plain radiographs
complete proximal obstruction
incomplete obstruction
complete distal obstruction
contrast studies
Case
Newborn with failure to pass meconium
Complete distal obstruction
jejunal atresia
meconium plug
Hirschsprung
small left colon
contrast enema
Normal colon
Microcolon
Ileal atresia
meconium ileus
total aganglionosis
Meconium Ileus
Radiologic Features
Meconium peritonitis
obstruction
Contrast Enema
Microcolon
Meconium plugs
in terminal ileum
Therapeutic
Hirschsprung Disease
Absence of myenteric plexus cells (aganglionosis)
of distal colon
Male:female 6:1
Present with obstruction,
constipation
Complications of perforation, peritonitis
Dx: rectal biopsy
Hirschsprung Disease
Enema can be
normal in neonates
Transition zone
between normal
and stenotic
segment
Hirschsprung disease
Barium retention over 24 hours
Case
6 week old with nonbilious vomiting
Hypertrophic Pyloric Stenosis
Hypertrophy of pyloric muscle
80% male, commonly first born
2 weeks - 4 months of age
Caffeys,1993
Hypertrophic Pyloric Stenosis
Nonbilious projectile vomiting
Dehydration/alkalosis
Weight loss
Palpable olive
RUQ
Hypertrophic Pyloric Stenosis
UGI
String, shoulder, beak and tit
signs
Hypertrophic Pyloric Stenosis
US evaluation
Thick antropyloric muscle
>3.5 mm most accurate
Elongated pylorus
Channel length >17 mm
Case
5 year old with 3 episodes of painless rectal
bleeding.
Meckel Diverticulum
Omphalomesenteric/vitteline duct
remnant open at ileal end
15% ectopic gastric mucosa
4% of population
Within 2 feet of ileocecal valve
Most asymptomatic, 2% complications
intussusception,volvulus,hemorrhage
Meckels Diverticulum
May present with ulceration/hemorrhage
Obstruction from intussusception,
volvulus, diverticulits
Tc-99m pertechnetate scan
Uptake by chief cells of ectopic gastric
mucosa
Accumulation in right midabdomen or
right lower quadrant.
Case
5 year old with right lower quadrant pain
Appendicitis
Most common cause of abdominal surgery in
children
Nausea/vomiting, anorexia, fever
30-45% atypical presentation
retrocecal,pelvic, perforated
perforation rate as high as 60% in children
Rare in infants, increase frequency w/ each yr of
childhood
Appendicitis
Radiographs
fecolith 10-15%
RLQ mass,
SBO,
scoliosis
Appendicitis
US Evaluation
Graded compression (Puylaert, Rad 1986)
Appendicitis if
Noncompressible >6 mm
appendecolith (30%)
Look for extraluminal collections
Exclude alternative diagnosis
torsion,
PID,
intussusception,
mesenteric adenitis
.
CT if
patient large
difficult to examine
planning drainage intervention
Case
2 year old with intermittent colicky
abdominal pain.
Intussusception
Peak 5-9 months of age (75%)
Colicky pain, vomiting, abdominal mass
Currant jelly stools
>90% lymphoid hyperplasia
Pathologic lead point often in children> 4 yrs
must rule out Meckels diverticulum, polyp,
duplication, lymphoma
Pathologic lead point often in
children> 4 yrs -
must rule out Meckels diverticulum,
polyp,
duplication,
lymphoma
Intussusception
Radiologic Features
XR -RUQ mass, air crescent sign, SBO
US -Pseudokidney, target signs
Enema Contraindicated if peritonitis,
perforation or
septic shock
Surgical consult
exclude free air
IV
Case
12 year old with weight loss,
diarrhea
Inflammatory Bowel Disease
25% present prior to age 20
Crohns:Ulcerative Colitis 2:1
Abdominal pain, diarrhea, rectal bleeding
Inflammatory Bowel Disease
Crohns Disease - entire thickness, skip
areas, small bowel 50%
Terminal ileum most common site
gastric aphthous ulcers
Ulcerative Colitis-mucosa/ submucosa
rectum proximally without skip areas
Inflammatory Bowel Disease
Evaluation
UGI for terminal ileum,
fistula evaluation
BE for colonic mucosal evaluation
Inflammatory Bowel Disease
Evaluation
CT for interloop abscess, bowel
thickening
Colonoscopy for biopsy
Case
3 year old with palpable abdominal mass
Abdominal Mass
AXR- R/O stool, calcifications, bowel
obstruction
US- R/O UPJ obstruction,
helps plan for CT/MR
CT for tumor staging
Abdominal Mass
CT- IV and oral contrast
MRI- 3 plane imaging- useful for
hepatic lesions, spinal cord involvement
Neonatal Abdominal Mass
55%Renal UPJ, MCDK, RVT, IPKD
15% Gyn - ovarian cyst, dermoid
15% GI- duplication, mesenteric cyst
10% Retroperitoneal
neuroblastoma, adrenal hemorrhage
5% Hepatobiliary
hemangioendothelioma, mesenteric
hamartoma, choledocal cyst,
Pediatric Masses
Renal (50%)
Wilms, UPJ, IPKD
Retroperitoneal (25%)
NB,Teratoma,Lymphoma, rhabdo
GI(20%)
AP,intus,mes cyst, duplication,chol cyst
Gyn-(5%)
Ovarian cyst,torsion, hydrometrocopolpos
Case
5 year old female with urinary tract
infection and fever
Renal Work up
US- Anatomy
hydronephrosis,
duplex, ureterocele,
VCUG /cystogram-
reflux, PUV,
neurogenic bladder
CT- abscess, renal calculi, tumors
Renal Work up
Renal Lasix Scan- obstruction-
UPJ,UPJ,PUV
DMSA- UTI - scarring
Case
13 year old female with pelvic pain
GYN-Pelvic Pain
US
PID, TOA, Ectopic
Ovarian Cyst, hemorrhagic
cyst, torsion
Dermoid
Hydrometrocolpos
Case
3 year old with limp
Limping Child
Toxic synovitis
Septic arthritis
Osteomyelitis
Discitis
SCFE
Legg Perthes/AVN
DDH
Tumor
Occult fracture
Limping Child
Xray
US-
Bone Scan-
MRI-
Osteomyelitis
XR- 10-14 days
periosteal reaction, lytic sclerotic lesions
Bone scan
metaphyseal
MRI- for complications
abscess
myositis
Case
Two week old with hip click
DDH
Screen those at risk-
breech, Equinovarus deformity (forefoot and
hind foot varus), family history
Hip click
US 4-6 weeks of age
FU monthly
CT/MRI in spica cast
Hip Evaluation
STOP
No risk factors
US 4 wks
Risk factors
Normal Exam
US 4 wks
Stable Click
Us 1-2 wks
Unstable Click
Abnormal Exam
Clinical Exam